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Scrotal Gray-Scale and Color Doppler
Sonographic Findings in
Genitourinary Brucellosis
M. Metin Bayram, MD, Reşat Kervancıoğlu, MD
Department of Radiology, Faculty of Medicine, Gaziantep University, TR-Şahinbey, 27070, Gaziantep, Turkey
Received 12 August 1996; accepted 15 April 1997
ABSTRACT: Purpose. Brucellosis is an enzootic disease that is frequently transmitted from Brucellainfected animals and their products to humans
through the gastrointestinal tract. Genitourinary complications are seen in 2–10% of cases. We used sonography to investigate such complications in patients
from a Brucella-endemic area.
Methods. Between 1992 and 1996, 246 patients
were clinically and serologically diagnosed as having
brucellosis and were examined by sonography.
Results. Genitourinary complications were identified by sonography in 26 patients. Fifteen of these
patients had unilateral epididymo-orchitis, 6 had diffuse orchitis, and 5 had a focal hypoechoic testicular
lesion. An increase in the vascularity of the lesions
was seen in the 14 patients who also underwent color
Doppler examination. Spectral waveform analysis
showed a decrease in the resistance index in 9 patients. After medical treatment, all but 1 of the lesions
disappeared within 2 months; the last lesion persisted
for 6 months.
Conclusions. In areas in which brucellosis is endemic, when scrotal abnormalities are seen with grayscale or color Doppler sonography, the possibility of
genitourinary tract complications of brucellosis
should be considered. Simple Brucella tests may prevent unnecessary surgery. © 1997 John Wiley & Sons,
Inc. J Clin Ultrasound 25:443–447, 1997.
products and feces. It is also transmitted by direct
contact with and inhalation of infected feces. In
some regions of Turkey, particularly southeast
Anatolia, eating foods made with unpurified (raw)
milk is common, so cases of brucellosis in humans
are seen more frequently in southeast Anatolia
than in other places.
Clinically, more than 90% of patients with brucellosis have symptoms of extreme sweating,
chills, fever, weight loss, and complaints of diffuse
myalgias and back pain. Although an undulant
fever is a characteristic feature of the disease, it is
not seen in most patients. Insufficient treatment
or delay in starting treatment can increase the
rate of complications to as much as 30%. These
complications are seen mainly in the skeletal,
genitourinary, cardiovascular, gastrointestinal,
pulmonary, and neurologic systems, as well as in
the skin.1
In this prospective study, genitourinary complications in patients who were clinically and serologically diagnosed as having brucellosis were
investigated using gray-scale and color Doppler
sonography.
Keywords: genitourinary brucellosis; ultrasonography; color Doppler ultrasonography
PATIENTS AND METHODS
B
rucellosis is an enzootic disease that is transmitted to humans through the gastrointestinal tract by ingestion of Brucella-infected animal
Correspondence to: M. M. Bayram, Department of Radiology,
Şahinbey Hospital, Kolejtepe 27070, Gaziantep, Turkey
© 1997 John Wiley & Sons, Inc.
VOL. 25, NO. 8, OCTOBER 1997
CCC 0091-2751/97/080443-05
Between April 1992 and February 1996, 246 male
patients who were between the ages of 16 and 48
years and were clinically and serologically diagnosed as having brucellosis were referred for sonography to investigate the existence of genitourinary complications. Scrotal sonography was
performed with a Siemens SL-1 ultrasound scanner (Matsushita Communication Industrial Co.,
Ltd., Japan). In 14 of the 26 patients with gray443
BAYRAM AND KERVANCIOĞLU
scale abnormalities, color Doppler sonography
(Toshiba SSA-270A unit; Toshiba Corp., TochigiKen, Japan) was also performed. Longitudinal
and transverse gray-scale and color Doppler sonograms were obtained for each hemiscrotum. Spectral Doppler was performed in 9 of the 26 patients
with sonographic abnormalities. Peak systolic
and end-diastolic velocities were measured, and
the resistance index (RI) was calculated. The determination of abnormal vascularity was based
on a comparison of the affected and unaffected
hemiscrotum.
In addition to routine laboratory tests, a standard tube agglutination test and enzyme-linked
immunosorbent assay were done to measure levels of immunoglobulin M (IgM), IgG, and Brucella
antibodies. An antibody titer of 1:160 or more was
accepted as indicating infection. An increased
IgM level was accepted as indicating acute brucellosis and an increased IgG level as indicating
chronic brucellosis. Blood cultures were done in a
fully automatic specific unit (Bactec 9240; Becton
Dickinson, Sparks, MD). All patients were tested
for tuberculosis. For patients who had a focal hypoechoic testicular lesion, serum tumor markers
(b-human chorionic gonadotropin and afetoprotein) were measured.
All patients received antibiotic treatment (200
mg/day doxycycline plus 600 mg/day rifampin)
orally for 6–8 weeks. Repeat sonographic examinations were done during and after antibiotic
treatment. The complete resolution of symptoms
and laboratory abnormalities and the disappearance of abnormalities on gray-scale and color
Doppler sonograms done at the end of treatment
were considered confirmation of the diagnosis of
genitourinary brucellosis.
margins (Figure 1). All these focal lesions were at
the posterior aspect of the testis in proximity to
the epididymis. The size of focal lesions ranged
between 1.3 and 3.2 cm (mean, 2.3 cm). In the 15
patients diagnosed as having epididymo-orchitis,
the affected epididymis and testis were enlarged
and had hypoechoic echotextures. Hydroceles
were present in all 15, and 2 also had scrotal skin
thickening (Figure 2).
Color Doppler sonography was used on 14 of
the 26 patients with gray-scale lesions; 7 of them
had epididymo-orchitis, 3 had diffuse orchitis,
and 4 had a focal testicular lesion. Hyperemia resulted in an increase in both the size and number
of Doppler signals in the affected versus the unaffected testis and epididymis. Spectral waveform
analysis allowed calculation of RIs in 9 patients
who had testicular hyperemia and in 4 patients
who also had epididymal hyperemia. The RIs
from the testicular vessels ranged from 0.38 to
0.67 (mean, 0.48), and the RIs from the epididymal vessels ranged from 0.49 to 0.73 (mean, 0.62).
Venous flow was identified in 6 patients with testicular hyperemia and in 2 patients with epididymal hyperemia (Figure 3).
In all patients in whom antibody titers were
between 1:160 and 1:1,280, IgG levels were also
high. Blood cultures were positive for Brucella
melitensis in only 3 patients. The 1st patient of
the study group in whom sonography showed a
focal hypoechoic testicular lesion underwent orchiectomy because the urologists suspected a tumor. The resected specimen showed an abscess,
and cultures from it grew B. melitensis.
After medical treatment, lesions in all but 1 of
the patients disappeared within 2 months, as
RESULTS
Among 246 patients who were clinically and serologically diagnosed as having brucellosis, sonography revealed scrotal involvement in 26
(11%). Fifteen (58%) had unilateral involvement
of the epididymis and testis, and 11 (42%) had
unilateral involvement of the testis only. Bilateral involvement was not seen in any patient. The
clinical histories and physical examinations of 19
of these 26 patients revealed slight to severe scrotal pain and swelling. One patient also had a fever.
Among the 11 patients with testicular involvement only, the testis was enlarged with a hypoechoic echotexture in 6. The involved testis in
each of the other 5 patients was of normal size but
contained a focal hypoechoic lesion with distinct
444
FIGURE 1. Testicular brucellosis. Sonogram showing a focal hypoechoic lesion (open arrows) with distinct margins in the left testis
(LT).
JOURNAL OF CLINICAL ULTRASOUND
GENITOURINARY BRUCELLOSIS
FIGURE 2. Sonogram of the enlarged left testis in a patient with brucellar epididymo-orchitis. The echotexture is hypoechoic and heterogeneous. A hydrocele is present.
shown by follow-up sonography. The focal testicular lesion in the last patient did not disappear
until 6 months after treatment, although the testicular pain had subsided and laboratory results
had reverted to normal.
DISCUSSION
Insufficient treatment or a delay in starting treatment of brucellosis increases the rate of complications to as much as 30%.1 In the literature, genitourinary complications have been reported in 2–
10% of patients.2–5 In our study of this disease in
an endemic area, this rate was 10.6%.
The diagnosis of scrotal diseases is usually
based on clinical evaluation and laboratory results. Therefore, when epididymitis, epididymoorchitis, or orchitis is suspected, sonography is
more useful in enabling the exclusion of the possibility of abscess or tumor than it is in helping to
establish the primary clinical diagnosis.6 In our
study, we found scrotal involvement in 26 of 246
brucellosis patients referred to our department to
investigate the existence of genitourinary complications. The clinical histories and physical examination findings were positive for genitourinary
brucellosis in only 19 patients. Physical examination was unremarkable in each of the other 7 patients for whom sonography confirmed scrotal involvement. The sonographic confirmation of
genitourinary involvement in these patients
shows that sonography is superior to physical examination.
Differentiation of inflammatory scrotal lesions
from neoplasms and infarction may be possible
with sonography. A bilateral lesion is usually inVOL. 25, NO. 8, OCTOBER 1997
flammatory in origin. It is the unilateral lesion
that presents the diagnostic problem.7 Unilateral
epididymo-orchitis is the most common genitourinary complication in brucellosis.1 Infection that is
limited to the testis is rare; the epididymis is usually involved in patients who have acute inflammation. Sonographic characteristics are enlargement, a hypoechoic echotexture of the epididymis,
the presence of a hydrocele, and scrotal skin
thickening.8 In a normal epididymis, very few or
no vessels are seen on color Doppler sonograms,
but the size and number of vessels increase if the
epididymis is inflamed.9 The changes seen on
color Doppler images may precede changes evident on gray-scale sonograms.6 However, in this
study, because it was not possible to perform color
Doppler sonography on all patients, it could not
be proved whether color Doppler was superior to
gray-scale sonography.
Granulomatous lesions of the testes result
from a group of illnesses that are clinically and
pathologically similar. It is necessary to separate
those benign lesions from malignant tumors preoperatively. Testicular lesions are generally considered malignant until proven otherwise, but it
is possible that they may be benign. Testicular
brucellosis usually occurs secondarily with direct
contiguous spread from primary epididymitis. Because granulomatous inflammation can be associated with focal necrotic areas, clinical and sonographic findings resemble those seen in testicular
tumors.10,11
A lesion that is seen in proximity to the epididymis in the posterior aspect of the testis and that
appears focally hypoechoic with smooth margins,
must be differentiated from a tumor, tuberculous
involvement, trauma, and ischemia. Patel and
colleagues7 reported that a sharply or poorly defined hypoechoic or complex echogenic mass with
normal scrotal wall thickness and normal epididymis suggests a tumor. In our study, 5 patients in
whom a focal testicular lesion was seen had both
normal scrotal wall thickness and a normal epididymis. Patel et al7 also pointed out that inflammatory testicular lesions have hypoechoic and/or
hyperechoic patterns, are situated near the rete
testis, and have infiltrative borders. In our series,
the lesions were near the epididymis but had
smooth margins. The same authors reported that
the involved testis is always enlarged. In our
study, the testis was enlarged in cases of diffuse
involvement but was a normal size in cases of
focal involvement.
Color Doppler sonography enables the identification of an increase in the number of blood vessels in the area of the testis and epididymis. As a
445
BAYRAM AND KERVANCIOĞLU
FIGURE 3. Testicular brucellosis. (A) Gray-scale sonogram of the right testis (R.TES.)
showing a hypoechoic lesion (arrows). (B) Color Doppler sonogram in the same patient
showing increased vascularity in the hypoechoic lesion (arrows). (C) Spectral Doppler
waveform from the hypoechoic lesion showing low-resistance arterial flow and detectable venous flow below the baseline. The RI was 0.39.
result of the hyperemia that is associated with
acute scrotal inflammatory reactions, color Doppler sonography can suggest an inflammatory process.12–14 Analysis of the spectral waveforms may
be helpful in evaluating scrotal inflammatory diseases. In hyperemia, the RI may decrease. Normal RIs have been reported as being 0.7 or more
for epididymal arteries and 0.5 or more for testicular arteries.6,13,15,16 In our study, the mean RI
of epididymal arteries was 0.62 and that of testicular arteries was 0.48. These findings are in
agreement with previously reported results. Because testicular neoplasms 1.5 cm or smaller tend
446
to be hypovascular and those larger than 1.5 cm
tend to be hypervascular, color Doppler sonography may not clearly differentiate neoplasms from
acute inflammations.17–19
In patients with a focal hypoechoic lesion in the
testis on sonograms, the presence of a tumor is
strongly suspected, and orchiectomy is usually
performed. However, Tackett and colleagues20 reported that the final histologic diagnosis was benign disease in 50% of cases in which radical orchiectomy was performed for a presumed tumor.
The same investigators suggested that radical orchiectomy should not be done in patients who
JOURNAL OF CLINICAL ULTRASOUND
GENITOURINARY BRUCELLOSIS
have testicular lesions that are suspected of being
neoplasms on the basis of sonographic findings
alone. The first such patient in our series underwent an unnecessary orchiectomy for a presumed
tumor.
In regions where brucellosis is endemic, when
a scrotal lesion is demonstrated by gray-scale and
color Doppler sonography, the possibility of genitourinary tract complications of brucellosis
should be considered. A simple Brucella test can
prevent unnecessary operations and guide the
planning of medical treatment. However, it
should not be forgotten that the two conditions,
testicular tumor and brucellosis, may coexist.
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and Practice of Infectious Diseases, 3rd edn. London, Churchill Livingstone, 1990, p. 1735.
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States, 1965–1974. J Infect Dis 1977;136:312.
3. Lulu AR, Araj GF, Khateeb MI: Human brucellosis
in Kuwait: a prospective study of 400 cases. Q J
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5. Ibrahim AIA, Awad R, Shetty SD: Genito-urinary
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Radiology 1991;179:55.
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8. Feld R, Middleton WD: Recent advances in sonography of the testis and scrotum. Radiol Clin North
Am 1992;30:1033.
VOL. 25, NO. 8, OCTOBER 1997
9. Ralls PW, Jensen MC, Lee KP, et al: Color Doppler
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15. Middleton WD, Thorne DA, Melson GL: Color
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AJR Am J Roentgenol 1989;152:1237.
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